cardiovascular disease&treatment

1. cardiac dysrhythmia

1) normal sinus rhythm
• Atrial and ventricular rhythms are regular. Atrial and ventricular rates are 60 to 100 beats/minute. PR interval and QRS width are within normal limits.
2) sinus bradycardia
• Atrial and ventricular rhythms are regular. Atrial and ventricular rates are less than 60 beats/minute. PR interval and QRS width are within normal limits. • Treatment may be necessary if the client is symptomatic.

• Administer oxygen as prescribed.

• Administer atropine sulfate as prescribed.

• Be prepared to apply a non-invasive pacemaker (TCP) initially as prescribed if the atropine sulfate does not increase the heart rate sufficiently.

• Depending on the cause of the bradycardia, the client may need a permanent pacemaker.

3) sinus tachycardia
• Atrial and ventricular rhythms are regular. Atrial and ventricular rates are 100 to 180 beats/minute. PR interval and QRS width are within normal limits.
4) A-fib (Atrial fibrillation)
• Multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350 to 600 times/minute. Usually, no definitive P wave can be observed, only fibrillatory waves before each QRS.

• The atria quiver, which can lead to the formation of thrombi.

• Administer oxygen as prescribed.

• Administer digoxin as prescribed.

• Administer anticoagulants as prescribed because of the risk of emboli.

• Administer cardiac medications as prescribed to assist in the maintenance of cardiac output.

• Prepare the client for cardioversion as prescribed.

5) PVC (Premature Ventricular Contractions)
• Early ventricular complexes result from increased irritability of the ventricles. • Administer oxygen as prescribed.

• Administer amiodarone(Cordarone) as prescribed.

• For the client experiencing PVCs, notify the HCP if the client complains of chest pain or if the PVCs increase in frequency, are multifocal, occur on the T wave (R on T), or occur in runs of VT.

6) VT (Ventricular Tachycardia)
• Ventricular tachycardia occurs because of the repetitive firing of an irritable ventricular ectopic focus at a rate of 140 to 250 beats/minute or more. • stable client with sustained VT (with the pulse and no signs or symptoms of decreased cardiac output) • Administer oxygen as prescribed.

• Administer antidysrhythmics as prescribed.

• unstable client with VT (with pulse and signs and symptoms of decreased cardiac output) • Administer oxygen as prescribed.

• Administer antidysrhythmics as prescribed.

• Prepare for cardioversion if the client is unstable.

• pulseless client with VT • Initiate CPR until a defibrillator is available.
7) VF (Ventricular Fibrillation)
• VF is a chaotic rapid rhythm in which the ventricles quiver and there is no cardiac output. • Initiate CPR until a defibrillator is available. The client is defibrillated immediately with 200J (biphasic defibrillator) or 360J (monophasic defibrillator).

Cf.) asystole, PEA → CPR only (no shock)

• vagal maneuvers: Vagal maneuvers induce vagal stimulation of the cardiac conduction system and are used to terminate PSVT.

• carotid sinus massage: The HCP massages over one carotid artery for a few seconds to determine whether a change in cardiac rhythm occurs.

• Valsalva maneuver: The HCP instructs the client to bear down or induces a gag reflex in the client to stimulate a vagal response.

• TCP (TransCutaneous Pacing) : Non-invasive TCP is used as a temporary emergency measure in the profoundly bradycardic or asystolic client until invasive pacing can be initiated. Set the pacing rate as prescribed; establish a stimulation threshold to ensure capture.

• invasive transvenous pacing

• invasive epicardial pacing

• ★ permanent pacemakers client education: Postoperatively, limitation of arm movement on the operative side is required to prevent lead wire dislodgement. Instruct the client to report any fever, redness, swelling, or drainage from the insertion site. Report signs of dizziness, weakness or fatigue, swelling of the ankles or legs, chest pain, or shortness of breath. Wear loose-fitting clothing over the pulse generator site. Avoid contact sports. Instruct the client to inform airport security that he or she has a pacemaker because the pacemaker may set off the security detector. Instruct the client that most electrical appliances can be used without any interference with the functioning of the pacemaker; however, advise the client not to operate electrical appliances directly over the pacemaker site. Avoid transmitter towers and antitheft devices in stores. Use cell phones on the side opposite the pacemaker.

• cardioversion: Cardioversion is a synchronized countershock to convert an undesirable rhythm to a stable rhythm. A lower amount of energy is used than with defibrillation. Cardioversion can be an elective procedure performed by the HCP for stable tachydysrhythmias resistant to medical therapies or an emergent procedure for hemodynamically unstable ventricular or supraventricular tachydysrhythmias.
Obtain an informed consent if an elective procedure. Administer sedation as prescribed. If elective procedure, hold digoxin 48 hours and should receive anticoagulant therapy for 4 to 6 weeks pre-procedure and a TEE should be performed to rule out clots in the atria
Ensure that the skin is clean and dry in the area where the electrode paddles/hands-off pads will be placed. stop the oxygen during the procedure to avoid the hazard of fire. One paddle is placed at the third intercostal space to the right of the sternum; the other is placed at the fifth intercostal space on the left mid-axillary line. Pads for hands-off may be applied in an anterior-posterior position or apex-posterior position, and placement directly over breast tissue should be avoided. (오른쪽 쇄골 아래, 왼쪽 젖꼭지 아래) Be sure that no one is touching the bed or the client when delivering the countershock.
Priority assessment includes ability of the client to maintain the airway and breathing. Monitor for indications of a successful response, such as conversion to sinus rhythm, strong peripheral pulses, an adequate BP, and adequate urine output.

• defibrillation: Defibrillation is an asynchronous countershock used to terminate pulseless VT or VF. The defibrillator is charged to 200J (biphasic) or 360J (monophasic) for one countershock from the defibrillator.

• ICD (Implantable Cardioverter-defibrillator): Instruct the client to report any fever, redness, swelling, or drainage from the insertion site. Report signs of nausea, dizziness, fainting, weakness or fatigue, blackouts, and rapid pulse rates to the HCP. Wear loose-fitting clothing over the pulse generator site. Avoid contact sports. Advise the client of restrictions on activities such as driving and operating dangerous equipment. Instruct the client to avoid electromagnetic fields such as an MRI directly over the ICD because they can inactivate the device. During shock discharge, the client may feel faint or short of breath. Instruct the client to sit or lie down if he or she feels a shock and to notify the HCP.


2. CAD (Coronary Artery Disease)

• Coronary artery disease is a narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries. The development of collateral circulation takes time. • asymptomatic

• palpitation, chest pain

• dyspnea, cough

• syncope, excessive fatigue

• Assist the client to identify risk factors that can be modified. Instruct the client regarding a low-calorie, low-sodium, low-cholesterol, and low-fat diet, with an increase in dietary fiber.

• Administer medications as prescribed.

• atherectomy: a removed plaque from a coronary artery by the use of a cutting chamber on the inserted catheter or a rotating blade that pulverizes the plaque.


3. ★ MI (Myocardial Infarction)

• MI occurs when myocardial tissue is abruptly and severely deprived of oxygen.

• complications: dysrhythmias, ventricular rupture, cardiogenic shock, HF, pulmonary edema, thrombophlebitis, pericarditis, mitral valve insufficiency

• chest pain: crushing substernal pain, radiating to the jaw, back, and left arm, lasts 30 minutes or longer, unrelieved by rest or NTG, relieved only by opioids

• myoglobin → troponin → CK-MB

• ECG: ST elevation or not, T-wave inversion, an abnormal Q wave

• Cardiac catheterization is performed to determine the extent and location of obstructions of the coronary arteries.


• Administer oxygen as prescribed.

• Administer NTG as prescribed.

Administer morphine as prescribed.

Administer thrombolytic therapy.

• Monitor the BP closely after the administration of medications; if the SBP is lower than 100mmHg or 25mmHg lower than the previous reading, lower the head of the bed and notify the HCP.

• Ensure bed rest and place the client in a semi-Fowler’s position; stay with the client.

• Establish an IV access route.


• coronary artery stent


• Provide ROM exercises to prevent thrombus formation and maintain muscle strength.

• Progress to dangling legs at the side of the bed or out of bed to the chair for 30 minutes three times a day as prescribed after 36 hours following the acute episode.

• ★ PTCA (Percutaneous Transluminal Coronary Angioplasty): An invasive, non-surgical technique in which one or more arteries are dilated with a balloon catheter to open the vessel lumen and improve arterial blood flow. PTCA may be used for clients with an evolving MI, alone or in combination with medications to achieve reperfusion. Complications can include arterial dissections or rupture, embolization of plaque fragments, spasm, and acute MI.

• Obtain informed consent.

• Maintain NPO status after midnight.

• Assess the client for allergies to dye, iodine, or seafood. If a client taking metformin(Glucophage) is scheduled to undergo a procedure requiring the administration of iodine dye, the metformin is withheld 24 hours prior because of the risk of lactic acidosis.

• Establish intravenous access.

• Obtain vital signs.

• Prepare the insertion site (the groin area) by shaving and cleaning with an antiseptic solution if prescribed.

• Monitor vital signs and a cardiac rhythm at least every 30 minutes for 2 hours initially.

Monitor peripheral pulses and the color, warmth, and sensation of the extremity distal to the insertion site at least every 30 minutes for 2 hours initially. Notify the HCP if the client complains of numbness and tingling, if the extremity becomes cool, pale, or cyanotic, or if loss of the peripheral pulses occurs.

• Apply a sandbag or compression device (if prescribed) to the insertion site to provide additional pressure if required.

• Monitor for bleeding: if bleeding occurs, apply manual pressure immediately and notify the HCP. Monitor for hematoma; if a hematoma develops, notify the HCP.

• Keep extremity extended for 4 to 6 hours, as prescribed, keeping the leg straight to prevent arterial occlusion. Maintain strict bed rest for 6 to 12 hours, as prescribed, however, the client may turn from side to side. Do not elevate the head of the bed more than 15 degrees.

If the antecubital vessel was used, immobilize the arm with an arm board.

• Monitor for nausea, vomiting, rash, or other signs of hypersensitivity to the dye. Encourage fluid intake; if not contraindicated, to promote renal excretion of the dye and to replace the fluid loss caused by the osmotic diuretic effect of the dye.


• coronary artery stent: Coronary artery stents (bare metal or drug-eluting) are used in conjunction with PTCA to provide a supportive scaffold to eliminate the risk of acute coronary vessel closure and to improve long-term patency of the vessel.

• CABG (Coronary Artery Bypass Grafting): The occluded coronary arteries are bypassed with the client’s own venous or arterial blood vessels. It is cardiac surgery, which is expected a sternal incision and possible arm or leg incision(s).


4. angina

• Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply. • chest pain: crushing substernal pain, radiating to the jaw, back, and left arm, lasts less than 5 minutes, relieved by rest or NTG

• myoglobin, troponin, CK-MB is normal.

• ECG: Readings are normal during rest, with ST depression, or T-wave inversion during an episode of pain.

• The goal of treatment for angina is to provide relief from the acute attack, correct the imbalance between myocardial oxygen supply and demand, and prevent the progression of the disease and further attacks to reduce the risk of MI.

• Administer oxygen.

• Ensure bed rest and place the client in a semi-Fowler’s position; stay with the client.


5. ★ HF (Heart Failure)

• HF is the inability of the heart to maintain adequate cardiac output to meet the metabolic needs of the body because of impaired pumping ability. • Signs of left ventricular failure are evident in the pulmonary system. Signs of right ventricular failure are evident in the systemic circulation.

• Lt sided HF: dyspnea, tachypnea, crackles in the lung

• acute pulmonary edema: severe dyspnea, orthopnea, tachypnea, nasal flaring, use of accessory breathing muscles, wheezing and crackles, cough tachycardia, profuse sweating, cold and clammy skin, acute anxiety

• Rt sided HF: dependent edema, swelling of the fingers and hands, JVD (Jugular Venous Distention)

• nocturia

• Place the client in a high Fowler’s position with the legs in a dependent position.

• Administer oxygen, usually in high concentrations by a mask.

• Ensure an IV access device is in place.

• Prepare for the administration of a diuretic and morphine sulfate.

• Insert a Foley catheter.

• Monitor strict intake and output. Weigh diapers as appropriate for the most accurate output.

• Prepare for intubation and ventilator support if required.

• Document the event, actions taken, and the client’s response.

• Monitor daily weight to assess for fluid retention. A weight gain of 1kg/day (3lb/wk) is caused by the accumulation of fluid. A 2.2lb weight gain is equal to 1L of retained fluid.

[Pediatric] A weight gain of 0.5kg/day is caused.

• [Pediatric] Administer sedation as prescribed during the acute stage to promote rest. Feed when hungry and soon after awakening, conserving energy and oxygen supply.
Instruct the parents regarding the administration of digoxin.

• client education: Instruct the client to monitor daily weight. Instruct the client to balance periods of activity and rest. Advise the client to avoid isometric activities, which increase pressure in the heart. Instruct the client to avoid large amounts of caffeine, found in coffee, tea, cocoa, chocolate, and some carbonated beverages. Instruct the client about the prescribed low-sodium, low-fat, and low-cholesterol diet. Provide the client with a list of potassium-rich foods because diuretics can cause hypokalemia (except for potassium-retaining diuretics). Instruct the client regarding fluid restriction, if prescribed, advising the client to spread the fluid out during the day and to suck on hard candy to reduce thirst.


6.  cardiomyopathy

• Fibrosis of myocardium and endocardium, dilated chambers, mural wall thrombi prevalent

• non-obstructed, obstructed, restrictive

• Dysrhythmias, systemic or pulmonary emboli, moderate to severe cardiomegaly may result.

• similar to HF


• symptomatic treatment of HF

• Administer vasodilators

• control of dysrhythmias

• heart transplant

7. inflammatory diseases of the heart

1) pericarditis
• Pericarditis is an acute or chronic inflammation of the pericardium. HF or cardiac tamponade may result. • Sharp pain, aggravated by inspiration

• fever, chills

• fatigue, malaise

• pericardial friction rub

• signs of HF

• Position the client in a high Fowler’s position, or upright and leaning forward.

• Administer antibiotics for prescribed.

• Administer analgesics, salicylates, and non-steroidal anti-inflammatory drugs as prescribed.

• Administer oxygen.

• Provide adequate rest periods. No ABR. Limit activities to avoid overexertion and decrease the workload of the heart.

• Surgical incision of the pericardium (pericardiectomy) may be necessary.

2) myocarditis

• Acute or chronic inflammation of the myocardium as a result of pericarditis, systemic infection, or allergic response.
3) endocarditis
• Endocarditis is an inflammation of the inner lining of the heart and valves.

• Ports of entry for the infecting organism include the oral cavity, infections, and surgery or invasive procedures, including IV line placement.

• Emboli may result.

• Provide adequate rest balanced with activity to prevent thrombus formation.

• Maintain anti-embolism stockings.

• client education: Instruct the client to monitor intravenous catheter sites for signs of infection and report this immediately to the HCP. Encourage oral hygiene at least twice a day with a soft toothbrush and rinse well with water after brushing. Client should avoid use of oral irrigation devices and flossing to avoid bacteremia. Teach the client to cleanse any skin lacerations thoroughly and apply an antibiotic ointment as prescribed. The client should inform all HCPs of history of endocarditis and ask about the use of prophylactic antibiotics prior to invasive respiratory procedures and dentistry.

8. cardiac tamponade

• A pericardial effusion occurs when the space between the parietal and visceral layers of the pericardium fills with fluid.; an accumulation of fluid in the pericardial cavity. • pulsus paradoxes, narrowing pulse pressure,

• JVD with clear lungs,

• increased CVP, decreased cardiac output

• Administer fluids intravenously as prescribed to manage decreased cardiac output.

• Prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed. Monitor for recurrence of cardiac tamponade following pericardiocentesis.


9. ★ cardiogenic shock

• Cardiogenic shock is the failure of the heart to pump adequately, thereby reducing cardiac output and compromising tissue perfusion. • hypotension: SBP lower than 90mmHg

• tachycardia, poor peripheral pulse

• Urine output lower than 30mL/hour

• cold and clammy skin

• restlessness, disorientation, confusion

• Administer oxygen.

• Prepare for intubation and mechanical ventilation.

• Administer vasopressors and positive inotropic as prescribed.

• Monitor urinary output.


10. valvular heart disease

• Valvular heart disease occurs when the heart valves cannot fully open (stenosis) or close completely (insufficiency or regurgitation).

• Valvular heart disease prevents efficient blood flow through the heart.

• similar to HF • balloon valvuloplasty

• mitral annuloplasty

• commissurotomy, valvotomy

• valve replacement procedures: mechanical prosthetic valves, bioprosthetic valves

• client education after valve replacement procedures: Adequate rest is important. Heavy lifting (more than 10lb) is to be avoided, and exercise caution when in an automobile to prevent injury to the sternal incision. Anticoagulant therapy is necessary if a mechanical prosthetic valve has been inserted. Instruct the client concerning hazards related to anticoagulant therapy and to notify the HCP if bleeding or excessive bruising occurs. Instruct the client concerning the importance of good oral hygiene to reduce the risk of infective endocarditis. Brush teeth twice daily with a soft toothbrush, followed by oral rinses. Avoid any dental procedures for 6 months. Instruct the client concerning the importance of prophylactic antibiotics before any invasive procedure and the importance of informing all HCPs of history of valve replacement or repair.


11. vascular disorders

1) thrombosis
• When a thrombus develops, inflammation occurs, thickening the vein wall and leading to embolization.

• risk factor: hypercoagulability ulcerative colitis, venous stasis from varicose veins and heart failure, injury to the venous wall from IV injections, following surgery, fracture of the pelvis or lower extremities, pregnancy, use of oral contraceptives

2) thrombophlebitis
• phlebitis: vein inflammation associated with invasive procedures, such as IV lines

• thrombophlebitis: A clot (thrombus) forms in a vessel wall as a result of inflammation of the vessel wall.

• redness

• warm

• pain

• swelling

• Apply warm and moist soaks as prescribed to dilate the vein and promote circulation.
• ★ DVT (Deep Vein Thrombophlebitis): More serious than superficial thrombophlebitis because of the risk for pulmonary embolism. • calf or groin tenderness or pain

with or without swelling

• warm and pinkish-red color over the thrombus area

• Positive Homan’s sign

• D-dimer

• Measure and record the circumferences of the thighs and calves.

• Provide bed rest as prescribed. Apply a bed cradle and keep bedclothes off the affected leg.

Do not massage the extremity.

• Avoid using the knee gatch or a pillow under the knees. Elevate the affected extremity above the level of the heart as prescribed.

• Provide thigh-high or knee-high anti-embolism stockings as prescribed to reduce venous stasis and assist in the venous return of blood to the heart; teach how to apply and remove stockings.

• Administer intermittent or continuous warm and moist compresses as prescribed.

• Administer heparin therapy as prescribed. Administer warfarin as prescribed following heparin therapy.

• client education: Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated. Elevate the legs for 10 to 20 minutes every few hours each day. Plan a progressive walking program. Avoid smoking. Instruct the client concerning the hazards of anticoagulation therapy.

• inferior vena cava filter(IVC filter): Insertion of an intracaval filter that partially occludes the inferior vena cava and traps emboli to prevent pulmonary emboli.

• Ligation of Inferior vena cava: Suturering or placing clips on the inferior vena cava to prevent pulmonary emboli; done via abdominal laparotomy.

• embolectomy: Embolectomy is the removal of an embolus from an artery, using a catheter.

3) venous insufficiency
• Venous insufficiency results from prolonged venous hypertension, which stretches the veins and damages the valves. The resultant edema and venous stasis cause venous stasis ulcers, swelling, and cellulitis. • edema

• stasis dermatitis

• ulcer: Edges are uneven, ulcer bed is pink, and granulation is present.

• Avoid prolonged sitting or standing, constrictive clothing, or crossing legs when seated. Elevate the legs for 10 to 20 minutes every few hours each day. Instruct the client to elevate the legs above the level of the heart when in bed.

• Instruct the client to wear elastic or compression stockings during the day and evening as prescribed. Advise the client to put on a clean pair of elastic stockings each day; it may be necessary to wear the stockings for the remainder of life.

• Instruct the client in the use of an intermittent sequential pneumatic compression system, if prescribed. Advise the client with an open ulcer that the compression system is applied over a dressing.

• If an Unna boot (dressing constructed of gauze moistened with zinc oxide) is prescribed, the HCP will change it weekly. The wound is cleansed with normal saline before application of the Unna boot; povidone-iodine (Betadine) and hydrogen peroxide are not used because they destroy granulation tissue. The Unna boot is covered with an elastic wrap that hardens to promote venous return and prevent stasis. Occlusive dressings such as polyethylene film or a hydrocolloid dressing may be used to cover the ulcer.

4) varicose vein
• Distended, protruding veins that appear darkened and tortuous are evident. • Trendelenburg’s test • sclerotherapy

• laser therapy

• vein stripping


12. arterial disorders

1) Raynaud’s disease
• Raynaud’s disease is vasospasm of the arterioles and arteries of the upper and lower extremities. Vasospasm causes constriction of the cutaneous vessels.

• Attacks are intermittent and occur with exposure to cold or stress.

• blanching during vasoconstriction

• reddened tissue when relieved

• numbness, tingling

• a cold temperature at the affected body part

• Avoid the client to identify and avoid precipitating factors such as cold and stress.

• Instruct the client to avoid smoking.

• Advise the client to avoid injuries to fingers and hands.

• Administer vasodilators as prescribed.

2) PAD (Peripheral Arterial Disease)
• Chronic disorder in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients. • intermittent claudication

• aching pain that is more severe at night

• numbness, tingling

• elevational pallor and dependent rubor in the lower extremities

• a cold temperature at the affected body part

• diminished pulses in the distal extremities

• ulcer: Edges are even, ulcer bed is pale, and little granulation is present.

• Encourage prescribed exercise, which will improve arterial flow through the development of collateral circulation. Instruct the client to walk to the point of claudication, stop and rest, and then walk a little farther.

In severe cases of PAD, clients may sleep with the affected limb hanging from the bed or they may sit upright without leg elevation in a chair for comfort.

• Because swelling in the extremities prevents arterial blood flow and extreme elevation slows arterial blood flow to the feet, the client with PAD is instructed to elevate the feet at rest but to refrain from elevating them above the level of the heart.

• percutaneous transluminal angioplasty, with or without intravascular stent

• laser-assisted angioplasty

• bypass surgery: Inflow procedures bypass the occlusion above the superficial femoral arteries and include aortoiliac, aortofemoral, and axillofemoral bypasses; outflow procedures bypass the occlusion at or below the superficial femoral arteries and include femoropopliteal and femorotibial bypass.

3) Buerger’s disease (TAO, thromboangiitis obliterans)
• Buerger’s disease is an occlusive disease of the median and small arteries and veins
4) AA (Aortic Aneurysms)
• An aortic aneurysm is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of the aorta.

• The aneurysm can be located anywhere along the abdominal aorta.

• abdominal or lower back pain

• tenderness on deep palpation

• prominent, pulsating mass in the abdomen, at or above the umbilicus

• rupturing aneurysm: signs of shock, hematoma at flank pain

• Instruct the client with an AA to report immediately the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness.

• AAA resection: Surgical resection or excision of the aneurysm. The excised section is replaced with a graft that is sewn end to end.

• thoracic aneurysm repair: A thoracotomy or median sternotomy approach is used to enter the thoracic cavity. The aneurysm is exposed and excised, and graft or prosthesis is sewn onto the aorta.


14. hypertension & hypertensive crisis

• An individual classified with prehypertension has a systolic BP between 120 and 139 mmHg or diastolic pressure between 80 and 89 mmHg.

• Stage 1 hypertension can be classified as a systolic BP between 140 to 159 mmHg or diastolic pressure between 90 and 99 mmHg.

• Stage 2 hypertension can be classified as a systolic BP equal to or greater than 160 mmHg or diastolic pressure between 90 to 99 mmHg.

• maybe asymptomatic

• headache, dizziness, flushed face

• visual disturbances, tinnitus, epistaxis

• chest pain

• Weight reduction, if necessary, or maintenance or ideal weight.

• Initiation of a regular exercise program.

• Dietary sodium restriction to 2g daily as prescribed. water ↓, fat ↓, K↑

• Avoidance of smoking.

• Moderate intake of alcohol and caffeine-containing products.

• Relaxation techniques and biofeedback therapy.

• Elimination of unnecessary medications that may contribute to hypertension.

• pharmacological intervention

• A hypertensive crisis is any clinical condition requiring an immediate reduction in BP. The accelerated hypertension requires emergency treatment because target organ damage (heart, brain, kidneys, the retina of the eye) can occur quickly. • An extremely high BP; usually the diastolic pressure is higher than 120mmHg. • Maintain a patent airway.

• Monitor V/S, assessing the BP every 5 minutes.

• Maintain bed rest, with the head of the bed elevated at 45 degrees.

• Have emergency medications and resuscitation equipment readily available.

• non-modifiable factor: aging, family history, African-American race
• modifiable factor: obesity, hyperlipidemia, smoking, excessive alcohol, increased intake of salt or caffeine, stress
precipitating disorders or conditions: cardiovascular disorders, renal disorders, endocrine system disorders, pregnancy, medications (e.g., estrogens, glucocorticoids, mineralocorticoids)

• client education: Emphasize the importance of lifelong medication and the need for follow-up treatment. Instruct the client to avoid Over-The-Counter medications. Instruct the client to read labels of products to determine sodium content, focusing on substances listed as sodium, NaCl, or MSG (Monosodium Glutamate). Instruct the client to bake, roast, or boil foods, avoid salt in the preparation of foods, and avoid using salt at the table. Instruct the client that fresh foods are best to consume and to avoid canned foods.


15. [Pediatric] congenital heart disease

1) defects with increased pulmonary blood flow (acyanotic type)
• Intracardiac communication along the septum or an abnormal connection between the great arteries allows blood to flow from the high-pressure left side of the heart to the low-pressure right side of the heart.
① ASD (Atrial Septal Defect)

• ASD is an abnormal opening between the atria that causes an increased flow of oxygenated blood into the right side of the heart.

• signs and symptoms of decreased cardiac output • Defect may be closed during cardiac catheterization.

• Open repair with cardiopulmonary bypass may be performed.

② VSD (Ventricular Septal Defect)

• VSD is an abnormal opening between the right and left ventricles.

• Many VSDs close spontaneously.

• Defect may be closed during cardiac catheterization.

• Open repair with cardiopulmonary bypass may be performed.

③ PDA (Patent Ductus Arteriosus)

• PDA is the failure of the fetal ductus arteriosus to close within the first weeks of life.

• Indomethacin (Indocin) may be administered.

• Defect may be closed during cardiac catheterization.

• Open repair with cardiopulmonary bypass may be performed.

2) obstructive defects (acyanotic type)
• Blood exiting a portion of the heart meets an area of anatomical narrowing, causing obstruction to blood flow.
① AS (Aortic Stenosis)

• AS is a narrowing or stricture of the aortic valve, causing resistance to blood flow from the left ventricle into the aorta, resulting in decreased cardiac output.

• signs and symptoms of decreased cardiac output

• Children show signs of exercise intolerance, dizziness when standing for long periods, and chest pain.

• Defect may be dilated during cardiac catheterization.

• surgical aortic valvotomy

② PS (Pulmonary Stenosis)

• PS is narrowing at the entrance to the pulmonary artery.

• Defect may be dilated during cardiac catheterization.

• surgical pulmonary valvotomy

③ COA (Coarctation of the Aorta)

• COA is localized narrowing near the insertion of the ductus arteriosus.

• Management of the defect may be done via balloon angioplasty in children.
3) defects with decreased pulmonary blood flow (cyanotic type)
• An anatomical defect (ASD or VSD) between the right and left sides of the heart and obstructed pulmonary blood flow are present. Pressure on the right side of the heart increases, exceeding pressure on the left side, which allows desaturated blood to shunt right to left, causing desaturation in the left side of the heart and in the systemic circulation.
① TOF (Tetralogy of Fallot)

• Including 4 defects; VSD, PS, overriding aorta, right ventricular hypertrophy.

• Hypercyanotic spells (blue spells): Acute episodes of cyanosis and hypoxia occur when the infant’s oxygen requirements exceed the blood supply, such as during periods of crying, feeding, or defecating.

• hypoxemia • hypercyanotic spell: Place the infant in a knee-chest position. Administer 100% oxygen. Administer morphine sulfate. Administer fluids intravenously. Document occurrence, actions taken, and the infant’s response.

– surgical repair

4) mixed defects (cyanotic type)
• Fully saturated systemic blood flow mixes with the desaturated blood flow, causing desaturation of the systemic blood flow.
① truncus arteriosus

• Truncus arteriosus is the failure of normal septation and division of the embryonic bulbar trunk into the pulmonary artery and the aorta, resulting in a single vessel that overrides both ventricles.

• surgical repair


16. [Pediatric] rheumatic fever

• Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, blood vessels, CNS, joints, and skin. The most serious complication is rheumatic heart disease, which affects the cardiac valves, particularly the mitral valve.

• Rheumatic fever manifests 2 to 6 weeks after an untreated or partially treated group A B hemolytic streptococcal infection of the upper respiratory tract.

• chorea: involuntary movements of extremities

• carditis

• erythema marginatum

• polyarthritis

• subcutaneous nodules

• elevated CRP

• elevated ESR

• elevated ASO (Anti-Streptolysin O titer)

→ indicating streptococcal infection

• Provide bed rest during the acute febrile phase. Limit physical exercise in a child with carditis.

• Initiate seizure precaution.

• Control joint pain and inflammation with massage and alternating hot and cold applications as prescribed.

• Administer antibiotics as prescribed.

Administer salicylates and anti-inflammatory agents as prescribed.

• Advise the child to inform the parents if anyone in school develops a streptococcal throat infection.


17. [Pediatric] Kawasaki disease
(mucocutaneous lymph node syndrome)

• Mucocutaneous lymph node syndrome is an acute systemic inflammatory illness. Cardiac involvement is the most serious complication. • fever

• enlargement of cervical lymph nodes

• desquamation of the skin on the tips of the fingers and toes

• joint pain

• Monitor heart rate and rhythm.

Monitor mucous membranes for inflammation.

• Administer soft foods and liquids that are neither too hot nor too cold.

• Provide passive range-of-motion exercises to facilitate joint movement.

• Administer acetylsalicylic acid (aspirin). Avoid contact sports, if age-appropriate, if taking aspirin or anticoagulants.

• Administer immunoglobulin IV as prescribed. Avoid administration of MMR or varicella vaccine to the child for 11 months after intravenous immunoglobulin therapy, if appropriate.


18. [Pediatric] sickle cell anemia

• Hb A is partly or completely replaced by abnormal sickle Hb S. Hb S is sensitive to changes in the oxygen content of the RBC. Insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow.

• Situations that precipitate sickling include fever, dehydration, and emotional or physical stress. Any condition that increases the need for oxygen or alters the transport of oxygen can result in a sickle cell crisis.

• Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency. These include a vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis.

• The clinical manifestations occur primarily as a result of obstruction caused by sickled RBCs and increased RBC destruction.

• sickle-turbidity (Sickledex) for screening → Hb electrophoresis

• The sickling response is reversible under conditions of adequate oxygenation and hydration.

• Maintain adequate hydration and blood flow through oral and intravenously administered fluids.

• Administer oxygen and blood transfusion as prescribed to increase tissue perfusion.

• Assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return. Elevate the head of the bed no more than 30 degrees, avoid putting a strain on painful joints, and do not raise the knee gatch of the bed.

• Administer analgesics as prescribed.

No IM. No Demerol, because of the risk of normeperidine-induced seizures.

• Encourage consumption of a high-calorie, high-protein diet, with folic acid supplementation.


19. [Pediatric] iron deficiency anemia

• Iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBCs. • Increase oral intake of iron. Instruct the child and parents in food choices that are high in iron. The iron-fortified formula is needed for an infant. 4개월 이상 영유아는 모체로부터 받은 철이 고갈됨.

• Administer iron supplements as prescribed. Teach parents how to administer iron supplements.

• Intramuscular injection of iron using the Z-track method or IV administration of iron may be prescribed in severe cases of anemia.


20. [Pediatric] aplastic anemia

• Aplastic anemia is a deficiency of circulating erythrocytes and all other formed elements of blood, resulting from the arrested development of cells within the bone marrow. • Therapeutic management focuses on restoring function to the bone marrow and involves immunosuppressive therapy and bone marrow transplantation.


21. [Pediatric] hemophilia

• Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The most common types are factor 8 deficiency (hemophilia A or classic hemophilia) and factor 9 deficiency (hemophilia B or Christmas disease). • The primary treatment is the replacement of the missing clotting factor. Additional medications, such as agents to relieve pain or corticosteroids, may be prescribed depending on the source of bleeding from the disorder.

• Instruct parents regarding activities for the child, emphasizing the avoidance of contact sports and the need for protective devices while learning to walk. Assist in developing an appropriate exercise plan. Instruct the child to wear protective devices such as helmets and knee and elbow pads when participating in sports such as bicycling and skating. (○) skateboard (ⅹ)

• recommend: walking, swimming, archery

benefit > risk: cycling, tennis, baseball

not recommend: boxing, wrestling, motorcycle, racquetball, soccer, jungle gym


22. [Pediatric] von Willebrand’s disease

• Von Willebrand’s disease is characterized by a deficiency of or a defect in a protein termed von Willebrand factor. Von Willebrand’s factor protein also serves as a carrier protein for factor 8.


23. [Pediatric] B-Thalassemia major

• B-Thalassemia major is characterized by the reduced production of one of the globin chains in the synthesis of Hb.

• The incidence is highest in individuals of Mediterranean descent, such as Italians, Greeks, Syrians, and their offspring.

• Treatment is supportive. The goal of therapy is to maintain normal Hb levels by the administration of blood transfusions.

• Monitor for iron overload. Chelation therapy may be prescribed.